The Journal of Pain, Vol 16, No 9 (September), 2015: pp 825-835

Available online at www.jpain.org and www.sciencedirect.com

Adherence to Analgesics for Cancer Pain: A Comparative Study

of African Americans and Whites Using an Electronic
Monitoring Device

Salimah H. Meghani,*,y,z Aleda M. L. Thompson,* Jesse Chittams,* Deborah W. Bruner,x

and Barbara Riegel*,y
*Department of Biobehavioral Health Science, School of Nursing, University of Pennsylvania, Philadelphia,
Pennsylvania.
y
NewCourtland Center of Transitions and Health, Philadelphia, Pennsylvania.
z
Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.
x
Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

Abstract: Despite well-documented disparities in cancer pain outcomes among African Americans,
surprisingly little research exists on adherence to analgesia for cancer pain in this group. We
compared analgesic adherence for cancer-related pain over a 3-month period between African Amer-
icans and whites using the Medication Event Monitoring System (MEMS). Patients (N = 207) were re-
cruited from outpatient medical oncology clinics of an academic medical center in Philadelphia
($18 years of age, diagnosed with solid tumors or multiple myeloma, with cancer-related pain,
and at least 1 prescription of oral around-the-clock analgesic). African Americans reported signifi-
cantly greater cancer pain (P < .001), were less likely than whites to have a prescription of long-
acting opioids (P < .001), and were more likely to have a negative Pain Management Index
(P < .001). There were considerable differences between African Americans and whites in the overall
MEMS dose adherence, ie, percentage of the total number of prescribed doses that were taken (53%
vs 74%, P < .001). On subanalysis, analgesic adherence rates for African Americans ranged from 34%
(for weak opioids) to 63% (for long-acting opioids). Unique predictors of analgesic adherence varied
by race; income levels, analgesic side effects, and fear of distracting providers predicted analgesic
adherence for African Americans but not for whites.
Perspective: Despite evidence of disparities in cancer pain outcomes among African Americans,
surprisingly little research exists on African Americans’ adherence to analgesia for cancer pain.
This prospective study uses objective measures to compare adherence to prescribed pain medications
between African American and white patients with cancer pain.
ª 2015 by the American Pain Society
Key words: Cancer pain, African Americans, analgesics, adherence, electronic monitoring.

T
he Institute of Medicine report Relieving Pain in
America finds that one of the most robust findings
on differential pain outcomes pertains to African
Received January 20, 2015; Revised May 23, 2015; Accepted May 28, 2015.
Presented in part at the 32nd Annual Scientific Meeting of the American
Pain Society, New Orleans, May 8–11, 2013.
Supported by NIH Challenge Grant to S.H.M. (NIH/NINR RC1-NR011591).
No authors declared any financial or nonfinancial conflicts of interest.
Address reprint requests to Salimah H. Meghani, PhD, MBE, RN, FAAN,
Associate Professor, Department of Biobehavioral Health Sciences, New-
Courtland Center for Transitions & Health, University of Pennsylvania,
School of Nursing, Associate Fellow, Center for Bioethics, Claire M. Fagin
Hall, 418 Curie Boulevard, Room 337, Philadelphia, PA 19104-4217.
E-mail: meghanis@nursing.upenn.edu
1526-5900/$36.00
ª 2015 by the American Pain Society
http://dx.doi.org/10.1016/j.jpain.2015.05.009
Americans.16 Previous Institute of Medicine reports,42
accumulated reviews,1,8,11,12,26 and a meta-analysis23
provide a compelling demonstration that African Amer-
ican patients are less likely to receive analgesia for pain
in cancer and noncancer settings. There is also strong
evidence from studies conducted independently in
different geographic regions in the United States that
pharmacies in predominantly African American and
minority zip codes do not carry the opioids needed to
treat moderate to severe pain.13,30
Factors at the provider and system levels have been
documented in the literature, but surprisingly little is
known about adherence to analgesia for cancer pain
among African Americans. This issue is important
because analgesics remain the predominant and

825
826 The Journal of Pain
consistently reimbursable clinical paradigm for manag-
ing cancer pain. Although the National Comprehensive
Cancer Network guidelines for adult cancer pain31
include several complementary and alternative modal-
ities, they are not consistently reimbursed or lack
rigorous data on clinical effectiveness for cancer
pain.4,20 Thus, differential analgesic adherence may be
conceptualized as an important explanatory variable in
cancer pain outcomes.28
Most studies on analgesic adherence for cancer pain
have been conducted predominantly or exclusively
with white samples.27,28,32,44,48,54,56 The limited studies
that exist on African Americans are cross-sectional (eg,
computed adherence for the past 24 hours)39 and are
based on self-reported measures of adherence.2,22,39,51
Studies in noncancer settings comparing self-reported
measures of adherence with objective measures such as
electronic monitoring have found that subjective adher-
ence measures are not sufficiently accurate and overesti-
mate rates of adherence by 10 to 30%.3,7,10,14,19,55 Thus,
we compared analgesic adherence for cancer pain
between African Americans and whites longitudinally
using the Medication Event Monitoring System (MEMS;
MVW Switzerland Ltd, Sion, Switzerland). The specific
aims were to 1) compare adherence to prescribed
around-the-clock (ATC) analgesic between African Amer-
icans and whites with cancer-related pain over a 3-month
period; and 2) identify unique predictors of ATC anal-
gesic adherence for cancer pain for African Americans
and whites.
Methods
Design and Study Population
The study was a 3-month observational design with
repeated measures at 2 time points, ie, baseline (T1)
and 3 months (T2). Patients were recruited from 2
outpatient medical oncology clinics of an academic
medical center in Philadelphia between December
2009 and August 2011. Inclusion was based on self-
identified African Americans or whites, at least
18 years of age, diagnosed with solid tumors or multi-
ple myeloma, with cancer-related pain, and at least 1
prescription of oral ATC analgesic. Patients were
excluded if they were prescribed ATC analgesics using
a transdermal system (eg, fentanyl patch) because of
limitations of MEMS vials. The study was approved
by the institutional review board of the University of
Pennsylvania, and all patients provided informed
consent.
Study Measures
Index Analgesic
The information regarding prescribed ATC analgesics
(index medication) was gathered based on patient
self-reports during the baseline T1 interview and trian-
gulated with electronic medical records review. Index
analgesics were coded according to the World Health
Organization’s (WHO) analgesic ladder.52,53 This
Adherence to Analgesics for Cancer Pain
includes step 1 (nonopioid analgesics, eg, ibuprofen,
acetaminophen, naproxen); step 2 (weak opioids, eg,
codeine); and step 3 (strong opioids, eg, morphine,
oxycodone, methadone). The step 3 analgesics were
further coded according to immediate release and
extended or sustained release (long-acting) opioids
based on evidence of both differential prescription
and use of long-acting opioids by race.51 We computed
the Pain Management Index (PMI) for each patient
based on the WHO guidelines for treating cancer
pain.52,53 The PMI measure is based on the most
potent analgesic prescribed to a patient relative to
the level of his or her reported pain. PMI is calculated
by subtracting patient’s pain levels (‘‘worst pain’’ score
from the Brief Pain Inventory [BPI] coded as mild,
moderate, or severe) from the most potent analgesia
prescribed. A negative PMI implies inadequate
analgesic prescription relative to the reported pain
level.
MEMS Analgesic Adherence
Analgesic adherence was captured using MEMS.
MEMS is a medication bottle cap with a microprocessor
that records the occurrence and time of bottle opening
in real time. The primary measure of ATC analgesic
adherence in our study was ‘‘dose adherence’’ (percent-
age of the total number of prescribed doses that were
taken). For example, if a patient took 60 of 80 prescribed
doses over the study period, the ‘‘dose adherence’’ mea-
sure would be 75%.
Patients were instructed on the correct use of the
MEMS bottle during the baseline T1 interview. A
follow-up phone call was made to each participant
within 7 days of T1 to allow participants to ask any ques-
tions they may have about proper usage of the MEMS
bottle. Patients were instructed to use the bottle for
the duration of the study period and use the bottle
only to take the index medication, including any refills
for the index medication. They were asked to notify
the study staff of any changes in the medication dose
or frequency as well as document this information in a
medication log, in which they also maintained a record
of any instances of bottle opening other than when
taking the index medications.
PowerView software (MVW Switzerland Ltd) was
used to record and compute MEMS adherence. If a fre-
quency or medication change occurred during the
study period, a new medication entry (phase) was
created as a denominator, with the previous phase
ending at PowerView’s default time, 2:59 AM on the
day of the change, and the next phase beginning at
3:00 AM. If a dosage change occurred, the average of
the 2 (or more) dosages was reported, and no new
phase was created. If a patient reported (in writing
on the event log or orally with reasonable certainty
during the T2 interview) having taken doses that the
bottle did not record, the events were added to the
MEMS data. For example, added events might occur if
a patient took out 2 pills at 1 time and took the second
later in the day, or if the patient took out 6 pills for a
Meghani et al
3-day trip. Likewise, if a patient reported extra open-
ings for reasons other than taking the medication,
the extra openings were excluded from the MEMS
adherence calculation. Excluded events included
accidental openings and openings only to count pills
or refill the bottle.
Also, hospitalization periods were adjusted in the
analysis as a nonmonitored period beginning on the cal-
endar day of admission at 3:00 AM and ending on the cal-
endar day after discharge at 2:59 AM. Hospitalization
information (including facility name, dates, and primary
and secondary diagnoses) was obtained from self-
reports between the T1 and T2 dates, self-reports at
the T2 interview, and review of patient charts. Hospital-
ization duration was calculated by subtracting the
admission date from the discharge date.
Self-Reported Analgesic Barriers
Barriers Questionnaire II50 was used at baseline to
assess patients’ beliefs about management of cancer
pain. Barriers Questionnaire II is a 27-item instrument
that elicits pain management concerns in 8 domains: 1)
fear of addiction, 2) fear of tolerance, 3) fear of side ef-
fects, 4) fatalism about cancer pain, 5) desire to be a
good patient, 6) fear of distracting the health provider
from treating cancer, 7) fear that the analgesics impair
the immune system, and 8) concern that analgesics may
mask ability to monitor illness symptoms. For each
item, the responses range from 0 (do not agree) to 5
(agree very much). The recommended scoring is based
on mean scores on the total scale (27 items) and sub-
scales. The internal consistency of the scale is excellent
at .89.50
Analgesic Side Effects
Analgesic side effects were captured at baseline us-
ing the Medication Side-Effects Checklist,49 which
elicits information on the presence, type, and severity
of 8 common analgesic side effects during the past
week (0–10; no severity to extreme severity). The re-
ported internal consistency reliability (Cronbach a) is
greater than .80.
Pain Severity and Pain Impact
Pain severity and pain impact were measured at base-
line using the BPI.9 The tool assesses pain at its worst,
least, and average over the past week, and pain
currently experienced (pain now) on a 0 to 10 scale
(no pain to pain as bad as you can imagine). The psy-
chometrics of the BPI is well established for patients
with cancer, including minority patients with cancer.
Its Cronbach a ranges from .77 to .91.
Intentional versus Unintentional Nonadher-
ence
Morisky Medication Adherence Scale (MMAS),29 a
structured, 4-item, self-reporting measure, was used at
baseline to distinguish between both intentional (active)
and unintentional (passive) dimensions of nonadher-
ence. Statements corresponding to unintentional non-
The Journal of Pain 827
adherence include ‘‘I sometimes forget to take my pain
medicine’’ and ‘‘I am sometimes careless about taking
my pain medicine.’’ Statements that correspond to inten-
tional nonadherence include ‘‘When I feel better I some-
times stop taking my pain medicine’’ and ‘‘If I feel worse
when I take the pain medicine, sometimes I stop taking
it.’’ The participants were asked to indicate the extent
to which they agree with each statement on the MMAS
4-point scale. The scores for each of the 4 items are
aggregated to give a score ranging from 0 to 4; higher
scores indicate higher levels of reported nonadher-
ence.29 MAMS has established concurrent and predictive
validity, and its Cronbach a in different studies has
ranged from .61 to .86.
Demographic and Illness Variables
Self-reported demographic data were gathered on
age, gender, self-identified race and ethnicity, marital
status, education, income, and type of health insurance.
Illness-related variables collected from patients’ medical
records included type of cancer, stage of cancer, time
since cancer diagnosis, past history of drug or substance
abuse, comorbidities, and history of depression.
Statistical Analysis
All data were analyzed using SAS version 9.3.41 A pre-
diction model was constructed using a backward elimi-
nation method considering all variables that were
significant at the bivariate level (P < .2) as potential pre-
dictors. The backward elimination method involved
starting with all candidate variables in the model, then
deleting the variable (if any) that improves the model
the most by being deleted, and repeating this process
until no further improvement is possible (ie, all remain-
ing variables in the model are significant at the a = .05
level).
Separate models were run for African Americans and
whites to understand unique predictors of analgesic
adherence. The rationale for running separate models
by race rather than an overall model of adherence was
to identify potential intervention targets that may be
unique to each subgroup.
To assess potential bias caused by confounding, we
generated a series of bivariate analyses with adherence
as the outcome and several key variables obtained at
the initial visit as potential predictors. All variables that
were found to be statistically significant at the .2 level
were then considered as covariates in the final analysis.
Once the multivariable model was derived, each of the
original variables was re-entered into the model, 1 vari-
able at a time, by testing the most significant to least sig-
nificant variable to allow a previously insignificant
variable to become significant in the final model and re-
taining any variable that yielded a P value <.05.
Furthermore, to assess for potential bias because pa-
tients were lost to follow-up at month 3, we created a bi-
nary (yes/no) indicator variable for retention. We then
ran a series of bivariate analyses considering several
key variables obtained at the initial visit as potential pre-
dictors of retention status. We found no statistically
828 The Journal of Pain
significant predictors of dropout, which supports the sta-
tistical missing at random data assumption, suggesting
no significant bias as a result of retention.
Sensitivity Analysis for the Observer Effect
A critique of MEMS monitoring is that because of the
awareness of being observed, MEMS monitoring may
lead some individuals to modify aspects of their
medication-taking behavior.45,46 To account for this
potential source of bias, we created 2 separate
variables to determine the internal consistency
between the ‘‘dose adherence’’ outcomes containing
data from all the days monitored to the outcome
containing data with the first 30 days of observation
removed. The Spearman correlation between
adherence scores for all days monitored and the
adherence scores with the first 30 days excluded was
.97 (P < .001) for African Americans and .95 (P < .001)
for whites.
Because all Spearman correlations were significantly
large, there was strong internal consistency between to-
tal adherence scores and the total adherence scores with
the first 30 days of observations removed. Similar trends
in parameter estimates were observed when the
outcome with the first 30 days removed was used, with
little difference in the available data between all moni-
tored data and the data with 30 days of observations
removed. Based on this, the outcome containing the
adherence scores for all days monitored was chosen for
the final analysis.
Results
A participant and recruitment flowchart is presented
in Fig 1. Adherence data using MEMS were available
Figure 1. Participant and recruitment flowchart.
Adherence to Analgesics for Cancer Pain
for 207 patients (non-Hispanic whites = 121; non-
Hispanic African Americans = 86). There was no differen-
tial attrition from T1 to T2 based on key variables such as
race (P = .496) or participants’ general health status
(P = .612). The mean age of the group was 54 years
(SD = 11). There were significant differences between Af-
rican Americans and whites based on education, income,
type of health insurance, and presence of metastasis
(Table 1). However, there were no significant differences
between the groups based on age, gender, type of can-
cer, time since cancer diagnosis, comorbidity burden,
and past history of substance or alcohol abuse (Table 1).
Pain and Analgesic Prescription
Compared with whites, African Americans reported
significantly greater cancer pain, including higher BPI
‘‘worst pain’’ scores (P < .001); higher ‘‘least pain’’ scores,
indicating lower pain relief (P < .001); and negative PMI,
indicating inadequate analgesic prescription given the
pain levels (P < .001) (Table 2). There were no differences
in African Americans and whites in analgesic prescription
according to the WHO analgesic step. However, within
WHO step 3 analgesics, African Americans were less likely
to be prescribed long-acting opioids for pain relief
(P < .001). There was a significant difference between
groups on Morisky nonadherence items. More specially,
a larger percentage of African Americans reported being
forgetful (41% vs 27%, P = .043) and intentionally stop-
ping pain medicine when feeling better (58% vs 40%;
P = .009).
MEMS Analgesic Adherence
Patients’ adherence was monitored for an average of
88 days (standard deviation [SD] = 17) using MEMS. There
Meghani et al The Journal of Pain 829
Table 1. Demographic and Illness Characteristics
VARIABLE TOTAL (N = 207) WHITES (N = 121) AFRICAN AMERICANS (N = 86) P VALUES*
Age, y, mean (SD) 54 (11) 54 (12) 53 (10) .392
Time since cancer diagnosis, mo, mean (SD) 37 (35) 36 (35) 38 (36) .784
Charlson Comorbidity Index, mean (SD) 4 (3) 4 (2) 4 (3) .260
Gender
Male 90 (43) 59 (49) 31 (36) .069
Female 117 (57) 62 (51) 55 (64)
Marital status <.001
Married 110 (53) 84 (69) 26 (30)
Separated/divorced/widowed 56 (27) 19 (16) 37 (43)
Never married 41 (20) 18 (15) 23 (27)
Education .016
Elementary 3 (1) 1 (1) 2 (2)
High school 70 (34) 35 (29) 35 (41)
College/trade school 101 (49) 58 (48) 43 (50)
More than college 33 (16) 27 (22) 6 (7)
Income (US$) <.001
<30,000 73 (35) 24 (20) 49 (57)
30,000–50,000 36 (17) 15 (12) 21 (24)
50,000–70,000 37 (18) 26 (21) 11 (13)
70,000–90,000 24 (12) 21 (17) 3 (3)
>90,000 37 (18) 35 (29) 2 (2)
Health insurance <.001
Private 107 (52) 81 (68) 26 (30)
Medicaid 27 (13) 5 (4) 22 (26)
Medicare 41 (20) 21 (18) 20 (23)
Multiple 25 (12) 12 (10) 13 (15)
Other 6 (3) 1 (1) 5 (6)
Cancer type .907
Lung 32 (15) 21 (17) 11 (13)
Breast 38 (18) 21 (17) 17 (20)
Gastrointestinal 31 (15) 19 (16) 12 (14)
Genitourinary/reproductive 25 (12) 15 (12) 10 (12)
Multiple myeloma 34 (16) 17 (14) 17 (20)
Other solid tumors 47 (23) 28 (23) 19 (22)
Presence of metastasis .008
Yes 148 (72) 95 (78) 53 (62)
No 59 (28) 26 (22) 33 (38)
History of substance abuse .131
Yes 35 (17) 16 (13) 19 (22)
No 172 (83) 105 (87) 67 (78)
History of alcohol abuse .636
Yes 20 (10) 13 (11) 7 (8)
No 187 (90) 108 (89) 79 (92)
History of depression .236
Yes 87 (42) 55 (45) 32 (37)
No 120 (58) 66 (55) 54 (63)

NOTE. Values are n (%) unless otherwise indicated.

*P values are based on t-tests for continuous variables and c2 for categorical variables.

was no difference between African Americans and
whites in the number and frequency of medication
changes during the index period (Table 2). However,
there were considerable differences between African
Americans and whites in the overall analgesic adherence
(53% vs 74%, P < .001) as well as adherence according to
the WHO analgesic step (Table 2). On subanalysis, anal-
gesic adherence rates for African Americans ranged
from 34% for weak opioids to 63% for long-acting opi-
oids. For whites, adherence ranged from 55% for weak
opioids to 78% for long-acting opioids (Fig 2).
Unique Predictors of MEMS Analgesic
Adherence
Tables 3 and 4 present the findings of the unique
predictors of overall adherence (dose adherence) for
African Americans and whites, respectively.
African Americans
Income level was the strongest predictor of analgesic
adherence for cancer pain among African Americans
(Table 3). Compared with those who reported a
830 The Journal of Pain Adherence to Analgesics for Cancer Pain
Table 2. Analgesic Prescription and Pain Management Variables
TOTAL WHITES AFRICAN
VARIABLE (N = 207) (N = 121) AMERICANS (N = 86) P VALUES*
Index analgesic, n (%) .111
WHO step 1 19 (9.2) 7 (5.8) 12 (14.0)
WHO step 2 22 (10.6) 12 (9.9) 10 (11.6)
WHO step 3 166 (80.2) 102 (84.3) 64 (74.4)
Negative PMI, n (%) <.001
Yes 18 (8.7) 5 (4.13) 13 (15.1)
No 189 (91.3) 116 (95.9) 73 (84.9)
Prescription of long-acting opioids, n (%) <.001
Yes 117 (56.5) 82 (67.8) 35 (40.7)
No 90 (43.5) 39 (32.2) 51 (59.3)
MMAS unintentional; forgetfulness, n (%) .043
Yes 68 (32.9) 33 (27.3) 35 (40.7)
No 139 (67.1) 88 (72.7) 51 (59.3)
MMAS unintentional; carelessness, n (%) .839
Yes 35 (16.9) 21 (17.4) 14 (16.3)
No 172 (83.1) 100 (82.6) 72 (83.7)
MMAS intentional; stop when feel better, n (%) .009
Yes 98 (47.3) 48 (39.7) 50 (58.1)
No 109 (52.7) 73 (60.3) 36 (41.9)
MMAS intentional; stop when feel worse, n (%) .739
Yes 34 (16.4) 19 (15.7) 15 (17.4)
No 173 (83.6) 102 (84.3) 71 (82.6)
Worst pain (BPI, 0–10) 6.4 (3) 5.9 (3) 7.0 (2) <.001
Least pain (BPI, 0–10) 3.3 (2) 2.8 (2) 4.0 (2) <.001
Average pain (BPI, 0–10) 4.7 (2) 4.1 (2) 5.3 (2) <.001
Pain interference (BPI, 0–70) 35.2 (16) 33.6 (15) 37.6 (16) .086
Severity of side effects (MSEC, 0–80) 25.2 (15) 23.8 (13) 27.1 (17) .130
Barriers Questionnaire (BQ-II, 0–135) 66.8 (20) 64.5 (19) 70.0 (21) .052
Number of index medication changes during the study period .05 (.24) .06 (.23) .05 (.26) .744
Number of medication frequency changes during the study period .14 (.40) .18 (.46) .09 (.29) .094
Total number of analgesics prescribed (excluding coanalgesics) 2.1 (.80) 2.1 (.79) 2.0 (.82) .711
Total number coanalgesics prescribed .24 (.50) .24 (.51) .23 (.47) .920
% overall adherence 65.1 (34.5) 73.7 (31.5) 52.8 (34.9) <.001
Number of MEMS days monitored 87.6 (16.7) 86.8 (15.5) 88.4 (17.9) .486
% adherence by WHO step
WHO step 1 50.6 (33.5) 59.5 (37.5) 45.4 (31.5) .391
WHO step 2 45.2 (31.8) 54.9 (28.6) 33.6 (33.0) .121
WHO step 3 69.3 (33.7) 76.9 (30.7) 57.3 (35.1) .000
% adherence by long-acting opioids only 73.6 (31.0) 78.1 (29.2) 62.9 (32.9) .015

NOTE. Values are mean (SD) unless otherwise indicated.

Abbreviations: MSEC, Medication Side-Effects Checklist; BQ, Barriers Questionnaire.
*P values are based on t-tests for continuous variables and c2 for categorical variables.

household income of more than $50,000 a year, those
between $10,000 and $50,000 a year had a 25.89% lower
percentage of adherence (P = .002) and those with less
than $10,000 a year had a 41.83% lower percentage of
dose adherence (P < .001). Also, clinical variables were
significant in explaining nonadherence in African Amer-
icans. For instance, for each unit increase in the severity
of analgesic side effects, the percentage of dose adher-
ence decreased by 1.39 (P < .001). Similarly, for each
unit increase in concern about distracting the doctor
from curing the disease, the percentage of dose adher-
ence decreased by 7.44 (P = .002). The Morisky subscale
of intentional nonadherence was also a strong predictor
of dose adherence for African Americans. Those who
reported intentional nonadherence (ie, stopping analge-
sics when feeling better) had a 22.17% lower percent-
age of dose adherence (P < .001). On the other hand,
the number of analgesic side effects reported and the
number of analgesics prescribed were associated posi-
tively with dose adherence. This model was statistically
significant and explained 44% of the variance for dose
adherence for African Americans.
Whites
The intentional nonadherence subscale (ie, stopping
prescribed analgesics when feeling better or worse)
was the strongest predictor of dose adherence for whites
(Table 4). Those who reported stopping analgesics when
feeling better had a 23.67% lower percentage of dose
adherence (P < .001). Similarly, those who reported
Meghani et al
Overall Adherence WHO Step 1
78%
77%
74%
60%
55%
Whites
Figure 2. MEMS dose adherence by race and type of analgesic.
stopping analgesics when feeling worse had an 18.56%
lower percentage of dose adherence (P = .010). Clinical
variables such as length of pain due to cancer and pain
levels also predicted dose adherence for whites. For
every unit increase in time since cancer diagnosis (in
months), dose adherence increased by .16% (P = .026),
whereas for every unit increase in ‘‘least pain’’ (higher
scores indicate lower pain relief), dose adherence
decreased by 2.88% (P = .041). This model was statisti-
cally significant and explained 30% of the variance for
dose adherence for whites.
Discussion
‘‘Drugs don’t work in patients who don’t take them’’
(C. Everett Koop).36 By the same token, not taking medi-
cation is a behavioral representation of what may be
right or wrong for the patient in a medication treatment
setting. We found that analgesic adherence was low for
both whites and African Americans but it was consider-
ably lower for African Americans.
Most existing interventions to improve cancer pain
outcomes are conceived within a psychoeducational
paradigm that focuses on knowledge transfer to
address attitudes and barriers to opioid use.17,40,43 A
systematic review of the effectiveness of such
interventions for cancer pain management found that
although the interventions improved knowledge
about cancer pain management in most of the studies
(73%), most did not improve reported adherence to
analgesics.35 These findings were confirmed in another
meta-analysis5 that found no benefit of educational in-
terventions on analgesic adherence or pain-related
interference. This indicates that the knowledge path
to improving analgesic adherence or cancer pain out-
comes may be inadequate.
Consistently, we found that most common analgesic-
related fears (including addiction concerns) did not
explain objective analgesic adherence for cancer pain
for African Americans or whites. Most of the identified
predictors of objective adherence may be thought of as
circumstantial or experiential, likely based on patients’
The Journal of Pain 831
WHO Step 2 WHO Step 3 Long AcƟng Opioids Only
P<.001
63%
57%
53%
45%
34%
African Americans
previous clinical experience of cancer pain management
or clinician–patient interaction. Furthermore, African
Americans had more of such barriers (eg, need for
more information about pain medications, fear of
distracting or annoying clinicians, and concern for side
effects) than whites.
Similar findings were supported in a previous study of
adherence to analgesia for cancer pain (using subjective
measures of adherence and African American patients
only).39 The investigators found that addiction concerns
were not correlated with adherence for WHO step 2 or
step 3 analgesics; pain intensity, side effects, and fear
of distracting clinicians were associated with analgesic
adherence in African Americans with cancer pain.
Similarly, in our study, an increase in the severity of side
effects was associated with lower adherence to analgesia
for African Americans but not for whites. Moreover,
more adherent African Americans reported a greater
number of analgesic side effects at baseline, suggesting
disparities in analgesic management of adverse effects
in African Americans. The higher burden of side effects
in African Americans may also be related to the choice
of analgesics in African Americans. A recent study25
found that after controlling for the type of health insur-
ance, African Americans with cancer pain had 71% lower
odds of receiving a prescription of oxycodone than white
patients (P < .001) and they were more likely to be pre-
scribed morphine even in the presence of renal insuffi-
ciency. The investigators further reported that the type
of analgesics prescribed partially mediated the reported
adverse analgesic effects.25
In whites, lower pain relief (higher ‘‘least pain’’ scores)
predicted lower adherence to analgesia, whereas time
since cancer diagnosis, possibly indicating disease
severity, predicted greater analgesic adherence. Consis-
tently, in a previous analysis to understand trade-offs
that African Americans and whites use in making cancer
pain decisions, we found that African Americans were
more likely to make decisions on analgesic use based
on side effects, whereas whites were more likely to
make decisions on analgesic use based on the amount
of relief expected from using pain medications.24
832 The Journal of Pain Adherence to Analgesics for Cancer Pain
Table 3. Unique Predictors of Analgesic Adherence for African Americans
VARIABLE b COEFFICIENTS* STANDARD ERROR P VALUE
Household income (US$)
<10,000 41.828 9.207 <.001
10,000–50,000 25.894 8.188 .002
>50,000 (reference) — — —
Feel the need to receive further information about pain medication
Yes 25.629 9.381 .008
No (reference) — — —
Intentional nonadherence (‘‘When I feel better I sometimes stop taking my pain medicine’’)
Yes 22.174 6.131 <.001
No (reference) — — —
Total number of analgesics prescribed (excluding coanalgesics) 10.720 3.836 .007
Number of analgesic side effects 9.812 2.675 <.001
Fear that if doctors have to deal with pain they will not concentrate on 7.440 2.256 .002
curing the disease (0 = do not agree at all, 5 = agree very much)
Fear that doctors might find it annoying to be told about pain (0 = do not 5.911 2.394 .016
agree at all, 5 = agree very much)
Severity of analgesic side effects 1.389 .406 <.001

NOTE. Model: (F(9,76) = 6.65, P < .001, R2 = .441).

*The b coefficients from the final prediction model represent slope coefficients for the continuous predictors and the difference from the reference category for the
categorical predictors. A large value implies a large effect size.

Another important finding of this study is the strong
negative linear relationship in the levels of income and
adherence to analgesia for cancer pain among African
Americans. Studies in nonpain settings have found that
higher out-of-pocket cost and household income less
than $20,000 are associated with medication nonadher-
ence behaviors, including decreasing the dose or fre-
quency of medications, failing to refill, or extending
time between the refills.15,37,38,47 In the setting in
which patients refill their pain medications, they may
save pain medications until they cannot stand pain or
hoard pain medications for when pain is severe, a
behavior termed medication triaging.21 Although
studies of medication triaging in the context of pain
are limited, there is some evidence that patients may
be nonadherent to pain medications to be able to afford
medications for other chronic conditions such as dia-
betes.18 Thus, low-income patients may compromise on
taking pain medications to be able to afford medications
considered as more important or lifesaving or even resort
to less expensive but also less potent over-the-counter
alternative therapies.18,21
The fact that African Americans with lower incomes
were less adherent brings to the forefront the impor-
tance of discussing cost and ability to pay when writing
an analgesic prescription. In the current clinical scenario,
management of multiple conditions and symptoms oc-
curs in isolation and by multiple health care providers, re-
sulting in accumulated cost and complexity for the
patients. In a national study, most patients (two-thirds)
with chronic illnesses reporting underuse of medications
because of cost-related concerns never discussed these
concerns with their clinicians.38 Of those reporting cost-
related nonadherence, the clinicians never asked them
about their ability to pay for medications or the patients
did not believe that clinicians could help.38 Clinicians
may take a more proactive role in assessing cost-related
issues potentially contributing to analgesic nonadher-
ence and provide assistance such as reviewing overall
medication regimens, simplifying regimens, changing
medications to less expensive alternatives when clinically
appropriate, or providing information about programs
that may assist with prescription medication cost.
Consistent with the study by Rhee et al,39 overuse of
analgesia among African Americans is not supported in
our study. Unlike adherence for some other chronic con-
ditions for which there is more agreement on adherence
cutoff rates, there is no agreement about which cutoff is

Table 4. Unique Predictors of Analgesic Adherence for Whites

VARIABLE b COEFFICIENTS* STANDARD ERROR P VALUE
Intentional nonadherence (‘‘When I feel better I sometimes stop taking my pain medicine’’)
Yes 23.672 5.315 <.001
No (reference) — — —
Intentional nonadherence (‘‘If I feel worse when I take the pain medicine, sometimes I stop taking it’’)
Yes 18.557 7.054 .010
No (reference) — — —
Least pain in last week (0 = no pain, 10 = pain as bad as you can imagine) 2.876 1.394 .041
Length of time since the diagnosis of cancer (mo) .160 .071 .026

NOTE. Model: (F(4,116) = 12.34, P < .001, R2 = .299).

*The b coefficients from the final prediction model represent slope coefficients for the continuous predictors and the difference from the reference category for the
categorical predictors. A large value implies a large effect size.
Meghani et al
34
valid for analgesic use for cancer pain. Previous non-
U.S. studies have used cutoffs of 70%32 to 100%.33,34
However, regardless of the cutoff used, the analgesic
adherence rates of 34 to 63% in African Americans are
considerably lower. Similar lower analgesic adherence
rates for cancer pain in African Americans were also
identified in another study (46%),39 even using subjec-
tive measures that typically overestimate adherence.
These findings should be a cause for concern for the
goal of achieving equity in clinical cancer pain outcomes.
Strengths and Limitations
This is the first study to our knowledge that has
compared adherence to analgesia for cancer pain and
its unique predictors between African Americans and
whites using objective measures of adherence over
time. However, some findings of our study are limited.
First, we limited objective monitoring of analgesics to 1
ATC analgesic. Because we used a MEMS vial for elec-
tronic monitoring, it was not feasible to monitor ATC
prescription in a patch form. However, we have no
reason to believe that analgesics in a patch form would
be prescribed disproportionately to African Americans,
an assumption that is needed to nullify our findings of
differential prescription of long-acting opioids by race.
Furthermore, although MEMS allows for long-term
assessment of adherence and detailed information
about patterns of prescription use, it does not guarantee
ingestion of medication. Vial opening other than for
medication taking, medication changes within the study
period, and medication holidays (eg, secondary to hospi-
talization) may result in inaccuracies in adherence mea-
surement. We minimized this potential source of bias
by accounting for cap openings other than for medica-
tion taking (eg, for refills), a change in frequency and
dose of analgesics during the study period, or medica-
tion holidays caused by hospitalizations (see the Study
Measures section). Despite these limitations, studies in
the noncancer pain setting comparing MEMS with a vari-
ety of subjective measures have concluded that MEMS
is one of the more accurate adherence measurement
approaches.6
Our study is limited in that there were unmeasured can-
cer (cancer treatment, medications other than analgesics
and coanalgesics, cancer treatment-related side effects,
cancer-related functional impairments) and psychiatric
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